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Overview

This Guidelines summary covers the diagnosis and management of gout. It includes recommendations on diagnosing gout, managing flares, long-term management of gout, and referral to specialist services.

This NICE guideline replaces NICE Technology Appraisal 164 and Evidence Summary 23.

Diagnosis and assessment

Symptoms and signs

  • Suspect gout in people presenting with any of the following:
    • rapid onset (often overnight) of severe pain together with redness and swelling, in 1 or both first metatarsophalangeal (MTP) joints
    • tophi.
  • Consider gout in people presenting with rapid onset (often overnight) of severe pain, redness or swelling in joints other than the first MTP joints (for example, midfoot, ankle, knee, hand, wrist, elbow).
  • Assess the possibility of septic arthritis, calcium pyrophosphate crystal deposition and inflammatory arthritis in people presenting with a painful, red, swollen joint.
  • If septic arthritis is suspected, refer immediately according to the local care pathway.
  • Consider chronic gouty arthritis in people presenting with chronic inflammatory joint pain.
  • In people with suspected gout, take a detailed history and carry out a physical examination to assess the symptoms and signs (see the first two recommendations in this section). 

Diagnosis

  • Measure the serum urate level in people with symptoms and signs of gout (see the first two recommendations in the previous section) to confirm the clinical diagnosis (serum urate level of 360 micromol/litre [6 mg/dl] or more). If serum urate level is below 360 micromol/litre (6 mg/dl) during a flare and gout is strongly suspected, repeat the serum urate level measurement at least 2 weeks after the flare has settled.
  • Consider joint aspiration and microscopy of synovial fluid if a diagnosis of gout remains uncertain or unconfirmed.
  • If joint aspiration cannot be carried out or the diagnosis of gout remains uncertain, consider imaging the affected joints with X-ray, ultrasound or dual-energy CT.

Information and support

  • Provide tailored information to people with gout and their family members or carers (as appropriate) at the time of diagnosis and during subsequent follow-up appointments. Explain:
    • the symptoms and signs of gout
    • the causes of gout
    • that the disease progresses without intervention because high levels of urate in the blood lead to the formation of new urate crystals
    • any risk factors for gout they have, including genetics, excess body weight or obesity, medicines they are taking, and comorbidities such as chronic kidney disease (CKD) or hypertension
    • how to manage gout flares and the treatment options available
    • that gout is a lifelong condition that benefits from long-term urate-lowering therapy (ULT) to eliminate urate crystals and prevent flares, shrink tophi and prevent long-term joint damage
    • where to find other sources of information and support such as local support groups, online forums and national charities.

      See also the recommendations on diet and lifestyle.

Managing gout flares

Treatment for gout flares

  • Offer a non-steroidal anti-inflammatory drug (NSAID), colchicine or a short course of an oral corticosteroid for first-line treatment of a gout flare, taking into account the person’s comorbidities, co-prescriptions and preferences.

    In June 2022, this was an off-label use of oral corticosteroids. See NICE’s information on prescribing medicines.
  • Consider adding a proton pump inhibitor for people with gout who are taking an NSAID to treat a gout flare.
  • Consider an intra-articular or intramuscular corticosteroid injection to treat a gout flare if NSAIDs and colchicine are contraindicated, not tolerated or ineffective.

    In June 2022, this was an off-label use of corticosteroid injections. See NICE’s information on prescribing medicines.
  • Do not offer an interleukin-1 (IL-1) inhibitor to treat a gout flare unless NSAIDs, colchicine and corticosteroids are contraindicated, not tolerated or ineffective. Refer the person to a rheumatology service before prescribing an IL-1 inhibitor.
  • Advise people with gout that applying ice packs to the affected joint (cold therapy) in addition to taking prescribed medicine may help alleviate pain. 

Follow-up after a gout flare

  • Consider a follow-up appointment after a gout flare has settled to:
    • measure the serum urate level
    • provide information about gout and how to self-manage and reduce the risk of future flares (see the section on information and support)
    • assess lifestyle and comorbidities (including cardiovascular risk factors and CKD)
    • review medications and discuss the risks and benefits of long-term ULT.

Diet and lifestyle

  • Explain to people with gout that there is not enough evidence to show that any specific diet prevents flares or lowers serum urate levels. Advise them to follow a healthy, balanced diet.
  • Advise people with gout that excess body weight or obesity, or excessive alcohol consumption, may exacerbate gout flares and symptoms.

Long-term management of gout

Management of gout with urate-lowering therapies

  • Offer ULT, using a treat-to-target strategy (see below), to people with gout who have:
    • multiple or troublesome flares
    • CKD stages 3 to 5 (glomerular filtration rate [GFR] categories G3 to G5)
    • diuretic therapy
    • tophi
    • chronic gouty arthritis.
  • Discuss the option of ULT, using a treat-to-target strategy, with people who have had a first or subsequent gout flare who are not within the groups listed in the previous recommendation (see below for when to start ULT).
  • Ensure people understand that ULT is usually continued after the target serum urate level is reached, and is typically a lifelong treatment.
  • Start ULT at least 2 to 4 weeks after a gout flare has settled. If flares are more frequent, ULT can be started during a flare (see the section on preventing flares when starting or titrating ULT).

Treat-to-target strategy

  • Start with a low dose of ULT and use monthly serum urate levels to guide dose increases, as tolerated, until the target serum urate level is reached.

Target serum urate level

  • Aim for a target serum urate level below 360 micromol/litre (6 mg/dl).
  • Consider a lower target serum urate level below 300 micromol/litre (5 mg/dl) for people with gout who:
    • have tophi or chronic gouty arthritis
    • continue to have ongoing frequent flares despite having a serum urate level below 360 micromol/litre (6 mg/dl).

Urate-lowering therapies

  • Offer either allopurinol or febuxostat as first-line treatment when starting treat-to-target ULT, taking into account the person’s comorbidities and preferences.
  • Offer allopurinol as first-line treatment to people with gout who have major cardiovascular disease (for example, previous myocardial infarction or stroke, or unstable angina).
  • Consider switching to second-line treatment with allopurinol or febuxostat if the target serum urate level is not reached or first-line treatment is not tolerated, taking into account the person’s comorbidities and preferences. See section above for guidance on treat-to-target strategy.

Preventing gout flares when starting or titrating urate-lowering therapy

  • Discuss with the person the benefits and risks of taking medicines to prevent gout flares when starting or titrating ULT.
  • For people who choose to have treatment to prevent gout flares when starting or titrating ULT, offer colchicine while the target serum urate level is being reached. If colchicine is contraindicated, not tolerated or ineffective, consider a low-dose NSAID or low-dose oral corticosteroid.

    In June 2022, this was an off-label use of NSAIDs and oral corticosteroids. See NICE’s information on prescribing medicines.
  • Consider adding a proton pump inhibitor for people with gout who are taking an NSAID or a corticosteroid to prevent gout flares when starting or titrating ULT. Take into account the person’s individual risk factors for adverse events.

    In June 2022, this was an off-label use of NSAIDs and corticosteroids. See NICE’s information on prescribing medicines.
  • Do not offer an IL-1 inhibitor when starting or titrating ULT to prevent gout flares unless colchicine, NSAIDs and corticosteroids are contraindicated, not tolerated or ineffective. Refer the person to a rheumatology service before prescribing an IL-1 inhibitor.

Monitoring serum urate level

  • Consider annual monitoring of serum urate level in people with gout who are continuing ULT after reaching their target serum urate level.

Referral to specialist services

  • Consider referring a person with gout to a rheumatology service if:
    • the diagnosis of gout is uncertain
    • treatment is contraindicated, not tolerated or ineffective
    • they have CKD stages 3b to 5 (GFR categories G3b to G5)
    • they have had an organ transplant.

 

© NICE 2022. Gout: diagnosis and management. Available from: www.nice.org.uk/guidance/ng219. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.

Published date: 09 June 2022.

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